Clinical Experience 7th October 2019 – 6 Hours

Patient 1 –
Patient 1 overview – started running from inactivity 8/52, pain in post. ankle/lower gastroc 2/52 P1 L, P2 R foot. Ran 10km 1/7, now Px intermittent 4/10 P1 R, P2 L. Px 2/10 at rest. EMP. NSAIDS has helped.
All FROM, FPROM, FRROM of ankle and knee. Slight Px in eversion of R ankle but difficult to reproduce. Very acute, effusion, redness no heat.
Palpations – Px over peroneal tendons. Clinical Impression: peroneal tendonitis due to sudden increase in load, intensity and frequency of running and possibly resultant of new shoes.

This patient had a very acute injury from a 10km run the day before. Although we were able to test A, P and R ROM, due to subjective we were able to devise an immediate plan of treatment and exercises based on this, without aggravating the inflammation. It was advised that the patient maintains their range of motion and starts to incorporate a strengthening program for the peroneal muscles by way of resisted eversion and resisted eversion with hell raises to allow for additional plantar-flexion.

The supposed analgesic effects of cryotherapy has been justification enough of it widespread use in the treatment of soft tissue injuries. It is suggested that the reduction in tissue temperatures reduce the conduction of nerves and subsequent stretch-reflex mechanisms, as well as reducing secondary tissue death by the resultant tissue adaptations by way of lower temperatures, resulting in slower rates of chemical reactions and subsequent metabolic demand for ATP and energy synthesis (Hubbard et al. 2004).
Other physiological effects include analgesia, vasoconstriction, reduction in swelling and inflammation (Malanga et al. 2015).

However, reviews by Hubbard and Denegar (2004) and Bleakley et al. (2004) found that in spite of proposed physiological mechanisms, there was a lack of clinical evidence, by way of randomised clinical control studies surrounding the use of cryotherapy and suggested that this could have been largely as a result of the inability to use blind subjects when applying ICE and as such subsequent research trials have still yet to be completed.
In a more recent review by Malanga et al. (2015), it was also found that there is still very little evidence to support cold therapy and its use on acute soft tissue injury treatment with regards to healing times and effectiveness. Collins (2008), later also reported that there remained insufficient evidence in support of cryotherapy having any effect of the outcome of soft-tissue injuries.
With such a significant lack in supporting evidence by way of randomised control studies, I found it hard to justify my use of this modality with this patient. My rationale behind it’s use was to reduce swelling and induce the effects of vasoconstriction and analgesia, however In order to justify this, I needed to find some supporting evidence. The only current study in support of cryotherapy, by way of cold water immersion (CWI) in mice, was recently conducted by Furtado et al. (2018), in which he found CWI an effective treatment option after high intensity exercise, encouraging a more efficient anti-inflammatory response from the injured tissue.

With the physiological effects of cold therapy on tissue healing and the recent findings from Furtado et al. (2018) in mind, in conjunction with updated recommendations from Bleakley et al. (2012) and previous reports from Hubbard and Denegar (2004) of cold therapy’s analgesic effects (even just for 30minutes) and the knowledge that ice application is not at the detriment of tissue healing, I feel confident that our decision to use the game ready as cryotherapy was supported and justified enough, considering the acute nature of the injury and our inability to continue with any other progressive exercise treatment with the current presence of effusion.

However, I will continue to keep up to date with newly released findings, should they become available, on the efficacy of RICE modalities and be open to discovering new methods of managing soft tissue inflammation. As guidelines are constantly changing, for example, in a review by Vuurberg et al. (2018) it was found that the commonly used ICE treatment for acute lateral ankle sprains is now not recommended.

In future treatments, it could be useful to follow principles published by Dubois and Esculir (2019) has recently published a short report on the need to re-evaluate the current guidelines of ice and move to a new way of thinking; PEACE & LOVE. Protect, Elevate, Compress, Educate then subsequent Load, optimism, Vascularisation and Exercise after the initial inflammation has subsided; none of which has any mention of ice or cold therapy.

Patient 2 –
Patient 2 overview – Started running 11/52, completed 10 week course, ended 2/52 ago but continuing running 2x week. Increased load quickly from nothing. Bilateral ‘tension’ in post. lower legs/gastroc. Ant. pain over tibia bilaterally. Px 3/10 dull ache, intermittent. Stretching helps, running agg. Static, not improving.
FROM, FPROM, FPROM. No other observations. Px on palpation of bilat. distal 2/3 of tibia. Medial Tibial Stress Syndrome possible in bilat. tibias. Muscle tension in gastrocs due to the increase in load over past 11 week.STM of triceps surae, predom. gastroc. STM of tib ant. K-tape over tibia with decom over area of most Px.
Isotonic/eccen. exercises to strengthen tib. post to improve muscular and strengthen arch and eventually stop using insoles (e.g tennis ball squeezes during heel raises, then heel drops). Continue running.

In an attempt to help the patient manage her flat footedness which the patient reported the need for the orthotic insole in her shoe, we suggested that tibialis posterior exercises would prove useful (Carmody et al., 2015). This review by Carmody et al. (2015) reported that tibialis posterior dysfunction was the leading cause for flat footedness and interestingly, also found it to be more common in middle aged overweight woman, which matched my patient.
In a study by Lee and Cho (2016) whereby 16 young subjects with pes planus were given a 6 week program of either intrinsic muscle strengthening exercises (control group) or intrinsic exercises and tibialis posterior foot exercises for 30 minutes, 5 times weekly. This study found that the combination of intrinsic foot and tibialis posterior exercises did improve plantar pressure and subsequent dynamic balance.

Similarly to tibialis posterior dysfunction, medial tibial stress syndrome was also found to be more prevalent in the female population (Moen, Tol, Weir, Steunebrink, & Winter, 2009) and could be as a result of the weakness in the tibialis posterior and resultant pes planus (Griebert et al., 2016). This patient also presented with symptoms showing medial tibial stress syndrome and from both the subjective and objective assessments, it became a diagnostic possibility, especially as 13-17% of running injuries and 35% of leg pain is caused by medial tibial stress syndrome (Griebert et al., 2016) and this is how the symptoms occurred.

STM was performed as treatment for tension in her triceps surae group and the exercises for tibialis posterior were demonstrated and given for rehabilitation at home in order to help strengthen the arch. In the meantime, I was able to apply K-tape to the medial shins, which in a study on 20 healthy subjects were compared to 20 with previous medial tibial stress syndrome were assessed walking over a pressure plate before and after k-tape application with findings showing a decease in medial pressure after the tape application (Griebert et al., 2016). I am therefore able to provide some evidence to the effectiveness of the kinesiology tape with regards to both the pes planus and symptoms regarding pain in the anterior tibialis.

Patient 3 and 4 –
Both of these patients presented with very similar symptoms and the treatment was also very similar. The clinical impressions were joint restrictions in Cx, Tx and Lx, tension in posterior musculature and shoulder and neck tension due to a history of previous joint or soft tissue pathology, possible malalignment and resultant muscle imbalances. Treatment, therefore was very similar and involved Bilat. Tx Grade IV mobs, Lx mobs, shoulder strengthening exercises, for example seated rows, resisted rows and pully for rhomboids etc, TheraBand resisted exercises, such as triphasic to include eccentric, isometric and concentric. I educated the patient on exercises to improve strength in posterior upper Tx musculature Exercises to open up and increase mobility.

From this treatment, I wanted to find out and fully understand the rationale behind performing both lumbar and thoracic mobilisations and not specifically cervical one, even though one of the patients reported improvements in the tension in their cervical spine and mobility in subsequent movements thereafter. From further reading, I was reassured to find out from one randomised clinical trial by Cho et al. (2017) of which recruited 32 subjects, 1 group for cervical mobilisations and the other for thoracic to compare the two for the treatment of forward head posture. In this trial it was found that the subjects who had thoracic mobilisation intervention as well as mobility exercises, compared with the cervical group, recorded improvements in a number of measures, but most relevantly to my patients, a decrease in the pain scale measurement scores (NPRS) and an increase in neck extension.
These findings help support my use of thoracic spine mobilisations and exercises for my patients’ neck pain and restricted cervical ROM.

Overall evaluation of clinic performance – I found that throughout the duration of the clinic session, I was taking too long with each client and each session, therefore, was running into the next. I have always found that time management has been a weakness and as such I will look to try and improve this; something that I am confident can be achieved as I gain more experience over the course of the year and as such be able to progress with treatment much more efficiently and confidently.

References – 

Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), 220–221. https://doi.org/10.1136/bjsports-2011-090297

Bleakley, C., McDonough, S., & MacAuley, D. (2004). The Use of Ice in the Treatment of Acute Soft-Tissue Injury: A Systematic Review of Randomized Controlled Trials. American Journal of Sports Medicine, 32(1), 251–261. https://doi.org/10.1177/0363546503260757

Carmody, D., Bubra, P., Keighley, G., & Rateesh, S. (2015). Posterior tibial tendon dysfunction: An overlooked cause of foot deformity. Journal of Family Medicine and Primary Care. https://doi.org/10.4103/2249-4863.152245

Furtado, A. B. V., Hartmann, D. D., Martins, R. P., Rosa, P. C., da Silva, I. K., Duarte, B. S. L., … Puntel, G. O. (2018). Cryotherapy: Biochemical alterations involved in reduction of damage induced by exhaustive exercise. Brazilian Journal of Medical and Biological Research, 51(11), 1–8. https://doi.org/10.1590/1414-431X20187702

Griebert, M. C., Needle, A. R., McConnell, J., & Kaminski, T. W. (2016). Lower-leg Kinesio tape reduces rate of loading in participants with medial tibial stress syndrome. Physical Therapy in Sport, 18, 62–67. https://doi.org/10.1016/j.ptsp.2014.01.001

Hubbard, T. J., Aronson, S. L., & Denegar, C. R. (2004). Does Cryotherapy Hasten Return to Participation? A Systematic Review. Journal of Athletic Training.

Hubbard, T. J., & Denegar, C. R. (2004). Does cryotherapy improve outcomes with soft tissue injury? Journal of Athletic Training.

Lee, D., & Choi, J. (2016). The Effects of Foot Intrinsic Muscle and Tibialis Posterior Strengthening Exercise on Plantar Pressure and Dynamic Balance in Adults Flexible Pes Planus. Physical Therapy Korea, 23(4), 27–37. https://doi.org/10.12674/ptk.2016.23.4.027

Malanga, G. A., Yan, N., & Stark, J. (2015). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine. https://doi.org/10.1080/00325481.2015.992719

Moen, M. H., Tol, J. L., Weir, A., Steunebrink, M., & Winter, T. C. D. (2009). Medial tibial stress syndrome: A critical review. Sports Medicine, 39(7), 523–546. https://doi.org/10.2165/00007256-200939070-00002

Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F. W., Van Den Bekerom, M. P., Dekker, R., … Kerkhoffs, G. M. M. J. (2018). Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956. https://doi.org/10.1136/bjsports-2017-098106

Leave a Reply

Your email address will not be published. Required fields are marked *